University of Iowa

Campus Security Authority Report Form

Date Reported to the CSA
Name of the Campus Security Authority Reporting the Crime
Who Reported to the CSA?
Victim Name (Optional)
Victim Phone Number - Optional
To your knowledge, was a law enforcement agency notified of this crime?
Name of Agency
Were Other Departments Contacted?
If you have an internal tracking number, you can enter it here.
Does the victim want the incident reported to law enforcement?
Location of the Incident
Time of Incident (Approximately)
Please describe the incident.
Part I Crime - Please indicate the incident category to the best of your ability.
Was this a Liquor, Drug, or Weapon Arrest or Referral?
Was this a VAWA Crime?
Is there any evidence this crime was motivated by bias?
If there was bias, please choose any/all categories of prejudice that apply:
If you answered yes to the bias, please provide a brief summary of the reasoning for the bias motivation.